Women, diabetics, dementia patients most likely to fall in 'doughnut hole'; Reform seeks to close coverage gap

Bloomberg BusinessWeek: "Among elderly Americans, women and those with diabetes and dementia are most likely to find themselves in the Medicare Part D drug plan 'doughnut hole,' the coverage gap that occurs after a beneficiary has reached the annual coverage limit but hasn't spent enough on drugs to qualify for catastrophic coverage. Researchers analyzed the records of more than 287,000 Medicare enrollees in eight states and found that 16 percent of them entered the doughnut hole. Nearly 3 percent entered the gap very early -- within the first 180 days of the year. Of the enrollees who entered the gap, only 7 percent eventually qualified for catastrophic coverage." The study appeared online March 9 in the Journal of General Internal Medicine (Preidt, 3/29).

The (N.J.) Star-Ledger: "The health care reform package provided a quick fix for hundreds of thousands of senior citizens who struggle to afford their prescription medicines each year. The sticky reimbursement problem, created by Medicare, Part D in 2006, became known as the 'doughnut hole' soon after the Part D drug benefit went into effect. Here's why: Prescription drug-taking participants received coverage of up to $2,830 a year — the participant paid 25 percent of the cost and Medicare covered the remaining 75 percent — and then they fell into a hole of no coverage until they spent another $3,610 for their medicines. When they reached a total spending of $6,440, they came out of the doughnut hole and became eligible for reimbursement again under Medicare's catastrophic coverage." However, few of these beneficiaries incurred the out-of-pocket expenses necessary "to climb out of the hole." Paul Precht, a spokesman for the Medicare Rights Center, said that when many beneficiaries fell into the doughnut hole, they would try to cut costs on medicines, sometimes cutting pills in half to make them last longer to stop taking medicines until the new year when they would be covered again (Todd, 3/29).

The Concord Monitor: "Some New Hampshire seniors may opt out of federally funded private insurance plans in the years ahead. And nursing homes fear changes for the worse in the care they'll be able to provide. Those are some of the possible consequences of $500 billion in Medicare spending cuts mandated by the new health care law. ... While President Obama has pressed the point that the reform package will not directly cut Medicare benefits, attempts to trim excess from the system may indirectly alter the way seniors receive care. A sizable chunk of the funding cuts -- about $136 billion -- comes from reducing payments to private insurers who offer Medicare Advantage plans, which provide Medicare benefits through those companies. The goal is to stop overpaying insurance companies by an average of 14 percent above what it costs to provide traditional Medicare, said Nora Super, AARP's director of federal government relations" (Spolar, 3/28).

KNDO/KNDU, an ABC News station in Yakima, Wash., reports on health care legislation: "What some seniors may find most surprising is not what's in the law, but what's not in it" (3/29).

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This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.